BOSTON – Last Wednesday, the Massachusetts House of Representatives passed legislation limiting the use of step therapy protocols, in which insurance companies refuse to pay for the prescription drugs prescribed by a patient’s health care provider until the patient first tries cheaper, and oftentimes ineffective, alternatives. The legislation establishes exceptions a patient can use to avoid their insurer’s step therapy protocol and requires both MassHealth and commercial insurers to provide a clear and transparent process for patients and their care team to request an exception.
“This is a healthcare bill designed to allow patients to get the life-changing care they need without needlessly going through all kinds of hoops before getting it,” said State Representative Richard M. Haggerty (D-Woburn). “This legislation will allow patients to utilize exceptions within an insurance carrier’s step therapy protocols and get the treatment or medication they need sooner.”
The legislation outlines four different circumstances that trigger the patient exception process, including:
1. The required treatment will harm the patient,
2. The required treatment is expected to be ineffective,
3. The patient previously tried the required treatment, or similar treatment, and it was ineffective
or harmed the patient,
4. The patient is stable on a current treatment and switching treatments will harm the patient.
Additional highlights of the legislation include:
• A requirement that MassHealth and commercial insurers adopt a “continuity of coverage” policy to
ensure patients do not experience any delay in accessing a treatment when requesting a step
• A requirement that MassHealth and commercial insurers approve or deny a step therapy exemption
request within three business days, or within one business day if a delay would cause harm to the patient.
• A requirement that commercial carriers annually report data related to step therapy exemption requests
and related coverage determinations to the Division of Insurance.
• The creation of a commission on step therapy protocols tasked with studying, assessing, and bi-annually
reporting on the implementation of step therapy process reforms made in this legislation.
“An Act Relative to Step Therapy and Patient Safety” (H.4929) passed the House of Representatives 153-0.
The legislation now heads to the Senate for their consideration.